CLM-2026-007022
Riverside Primary Care Associates, Family Medicine. Service 2026-04-16 at office (POS 11). Received 2026-04-19.
Member
Resolved through the identity graph
- Member
- Lisa Soto
- Member ID
- UHC-28518-82
- Date of birth
- 1980-08-16
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-412059
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7817
- Coverage period
- 2024-09-01 to present
- Deductible
- $1,009.84 of $1,500.0067%
- Out-of-pocket maximum
- $557.57 of $3,000.0019%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6920830281
- Network
- In network
- Rendering NPI
- 1690354208
- Location
- Phoenix, AZ · TIN 77-3257014
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $323.00 | $200.26 | $40.00 | $160.26 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | 25 | 1 | 2 | $184.00 | $114.08 | $0.00 | $114.08 | Paid |
| 3 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $158.00 | $97.96 | $0.00 | $97.96 | Paid |
| Totals | $665.00 | $412.30 | $40.00 | $372.30 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-519039
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-025001 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-16: MEDICARE-ADV-A (MA), effective 2024-09-01. | |
| Timely filing | Pass | Received 3 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Riverside Primary Care Associates (6920830281). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Riverside Primary Care Associates2026-04-16 14:11
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027156 | 2026-03-29 | Northgate Bone and Joint Center | $208.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.